The Washington Post
September 16, 2003
Proposals for Expanding Health Care Coverage
By Julie Ishida

While the uninsured are left to deal with the consequences of being uninsured, policymakers have designed a variety of proposals to expand access to health insurance. The majority of Americans polled in a 2003 survey by the Kaiser Family Foundation and the Harvard School of Public Health support increasing the number of people in the United States covered by health insurance, but there is no consensus on how to accomplish this.

Karen Davis, president of the Commonwealth Fund:

“The proposals that are now being talked about are more pragmatic and less ideological and more focused on building [on] what works currently. How can we find out what’s working now and add more people?”

Paul Ginsburg, president of the Center for Studying Health System Change:”The reason why individuals are uninsured differs so much that it is unlikely that a single provision is going to cover them all. We need different approaches for different segments of the population.”

Here’s a summary of the major approaches under discussion.

Universal Coverage Proposals:

* Single payer

* Employer mandate

* Individual mandate

Incremental Proposal:

* Expansion of Medicaid and Children’s Health Insurance Program (CHIP)
eligibility

* Subsidization of private insurance

* Creation of a system similar to the Federal Employees Health Benefits
(FEHB) Program

http://www.washingtonpost.com/wp-dyn/articles/A15812-2003Sep15_2.html

Comment: The messages of individuals such as Karen Davis and Paul Ginsburg have dominated the national dialogue on health care reform. They imply that only piecemeal measures are feasible.

But the failure to control increasing costs, combined with a failure to reduce the numbers of uninsured have created an awareness that we need a more aggressive approach toward reform.

The recent publicity surrounding the physicians’ proposal for national health insurance published in JAMA, and the administrative efficiency achievable by a single payer system published in NEJM, have regenerated an interest in looking again at truly universal models of health care coverage.

Washington Post reporter Julie Ishida exemplifies the changing dialogue as she now includes universal models in her list of proposals. Members of the media understand the need to broaden the debate. But we need to convince the leaders of those organizations which support comprehensive health care coverage that it is once again okay to discuss universal systems of reform.Davis and Ginsburg need to hear that message.

One more message that we need to deliver is that there are very fundamental differences between the single payer model of social insurance and other so-called universal proposals. As an example, SB 2, California’s employer mandate which passed last week (but not yet signed by Gov. Davis) will still fail to provide coverage for over four-fifths of those currently uninsured.

It will significantly increase costs because it fails to eliminate the administrative excesses and fails to provide any significant cost-containment features. It also represents flawed tax policy since it is regressively funded, providing tax advantages for the wealthy and a lower net cost of their coverage, a benefit not available to low income individuals. It falls so far short of single payer goals that it is inappropriate to consider it in the same general category of reform.

Let’s convince our policymakers that it is time to put everything on the table. But let’s also convince them that single payer needs to be in a special place on the table wherein the policies of all other models are challenged to meet the golden standard of a universal, single payer system of social insurance.

The New England Journal of Medicine
September 11, 2003
Health, Life Expectancy, and Health Care Spending among the Elderly
By James Lubitz, M.P.H., Liming Cai, Ph.D., Ellen Kramarow, Ph.D., and
Harold Lentzner, Ph.D.

Conclusions
The expected cumulative health expenditures for healthier elderly persons, despite their greater longevity, were similar to those for less healthy persons. Health-promotion efforts aimed at persons under 65 years of age may improve the health and longevity of the elderly without increasing health expenditures.

http://content.nejm.org/cgi/content/full/349/11/1048

Comment: Since living longer doesn’t increase health care costs, those who predict “bankruptcy” of Medicare are now limited to the premises that the numbers of Medicare beneficiaries will be too great, and that the increasing
technological costs will be excessive.

The ratio of retirees to workers will shift upward with the retirement of the baby boomers, but that increase is a relatively modest, finite number that is not “unaffordable” according to any reasonable actuarial forecast.And it will stabilize as the baby boomers transition through the other end of the life cycle.

The increase in health care costs is a major issue. But that is not a problem that is limited to the Medicare program. It applies to our entire health care system. There are many factors. Just a few of these are increased use of expensive technology, higher drug costs, higher pricing in the United States, and Overutilization of our higher capacity healthcare system. These are systemic problems that cannot be addressed simply by destroying Medicare as a program of social insurance.

We need structural reform of our health care system. A good start would be to revise the way that we pay for health care, keeping in mind the importance of access, equity and affordability.

Health Affairs
Web Exclusive
August 11, 2003

Excerpt from a letter from Stephen M. Davidson, Professor, Health Care Management, Boston University school of Management, responding to Alain Enthoven’s previous article on multiple-employer exchanges:

Alain Enthoven believes that the employment-based system has failed to control health care costs because so many employers offer their employees coverage from only a single source instead of from multiple sources that would compete for the employees’ business. His solution is to create multiple-employer exchanges,” which would offer members’ employees choices among plans.

I am not commenting on his diagnosis. However, the success of his prescription depends on the probability that it will actually reduce the cost of care. Since I believe the chances of that are slim for several reasons, in my view, Enthoven’s solutions will not work…

Managed care plans can contain costs for a time by paying lower salaries or fees, buying supplies in bulk, or reducing administrative staff. But the key to keeping them down is improving the system’s efficiency by changing the processes of care. As noted above, that is a complicated, costly undertaking that health insurance plans are unlikely to attempt unless the incentives are a lot stronger and more reliable than those that would result from Enthoven’s exchanges.

Excerpt from Alain Enthoven’s response to Davidson’s letter:

Davidson leaves me wondering what alternative he would suggest to motivate process improvement. Would he suggest a single payer? A single payer could offer important advantages, such as universal coverage and government monopsony power to counterbalance provider monopolies, but it seems unlikely that it could motivate process improvement. Yet if U.S. employers don’t make a radical change toward managed competition pretty soon, a single payer will become inevitable, if it isn’t already.

http://www.healthaffairs.org/WebExclusives/Web_Exclusive_Letters_Davidson_081103.htm#Davidson

Center on Budget and Policy Priorities
September 2, 2003
Reducing “Waste, Fraud, and Abuse”: One Percent Of What? Double-Counting and Other Budget Committee Mistakes Will Require Some Committees to Cut Entitlement Programs More than One Percent
By Richard Kogan

Today (September 2, 2003), House and Senate Committees are scheduled to
submit recommendations on how to reduce “waste, fraud, and abuse” in federal
“mandatory,” or entitlement, programs. In May, the House and Senate Budget
Committees directed 12 Senate committees and 15 House committees to find
ways to reduce entitlement programs; the Budget Committees issued dollar
targets for each of these committees, supposedly equal to one percent of the
total entitlement spending in each committee’s jurisdiction. The Budget
Committees’ calculations were flawed, however, in major and minor ways.
As a result, most committees are required to find savings that represent
substantially more than one percent of the entitlement spending under their
jurisdiction, and a few are required to find savings of less than one percent.

The Budget Committees’ largest error was to double-count the cost of certain
“trust fund” programs. Double-counting makes these programs look costlier
than they really are, and so makes the savings targets for committees with
jurisdiction over these programs higher than one percent. The Budget Committees double-counted the cost of all programs that have trust funds
into which the U.S. Treasury transfers money, with the trust fund then using
the transferred funds to make payments to (or on behalf of) program beneficiaries. Programs with such a funding structure include the military
retirement program, the civil service retirement program, and Part B of
Medicare (the Supplemental Medical Insurance program, which pays for
visits to physicians, rather than hospital bills).

This is double-counting, and is scrupulously avoided by CBO and OMB.In total, double-counting of this nature by the Budget Committees produces ten-year savings targets that are $24 billion too high.

The Budget Committees also erred with regard to programs where the federal
government acts as an agent in “passing through” to other entities certain
funds that it collects for specified purposes… When a budget account is not really a government “spending program” but essentially is a pass-through for other transactions, there is no possibility of reducing the costs by one percent.

http://www.cbpp.org/9-2-03bud.htm

Comment: A major problem with programs of social insurance is that conservatives, when in control, continue to reduce funding (though usually simply by failing to provide adequate inflationary increases). They then plead that the programs are ineffective and should be replaced with private
alternatives.

Using dishonest calculations cloaked as reductions in “waste, fraud,and abuse” is in itself fraudulent and abusive. We need to demand that our legislators protect our public programs such as Part B of Medicare.
Failing that, we should replace them with legislators who will.

Date: Thu, 4 Sep 2003 10:26:29 -0700
Subject: qotd: Relaxing EMTALA rules will result in lethal outcomes

Department of Health and Human Services
Centers for Medicare & Medicaid Services
42 CFR Parts 413, 482, and 489
[CMS-1063-F] RIN 0938-AM34

Medicare Program; Clarifying Policies Related to the Responsibilities of Medicare-Participating Hospitals in Treating Individuals with Emergency Medical Conditions

ACTION: Final rule.
SUMMARY: This final rule clarifies policies relating to the responsibilities of Medicare-participating hospitals in treating individuals with emergency medical conditions who present to a hospital under the provisions of the
Emergency Medical Treatment and Labor Act (EMTALA).

Excerpt:
(2) Exception: Application to inpatients.

(i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual.

http://cms.hhs.gov/providers/emtala/cms-1063-f.pdf

And…

Institute of Medicine
Care Without Coverage: Too Little, Too Late

Hospital-based Care

The poorer health status of uninsured adults at the time of hospitalization is compounded by experiences as inpatients. They receive fewer needed services, worse quality care, and have a greater risk of dying in the hospital or shortly after discharge.

Traumatic injuries: Surprisingly, provider response to traumatic injury can be influenced by insurance status. Uninsured trauma victims are less likely to be admitted to a hospital, receive fewer services when admitted, and are more likely to die than are insured trauma victims.

http://www.iom.edu/includes/DBFile.asp?id=4160

Comment: The way in which a problem is framed greatly influences the approaches to solving the problem.

The administration has elected to define the continued application of EMTALA
standards to an emergency patient, once that patient is admitted, as a burdensome and unnecessary regulatory requirement. Their solution is to waive EMTALA rules for emergency inpatients once admitted. Relaxing this requirement can only compound the negative outcomes described in the Institute of Medicine report.

Others would define the problem as impaired outcomes and even death resulting from lack of insurance coverage for many emergency patients. Most of us would agree that the solution for the problem framed in this manner should be to ensure that everyone has adequate health insurance coverage.

Should our administration begin supporting policies that improve health care
outcomes, or should it continue to place a higher priority on policies that reduce government oversight of serious deficiencies that adversely affect the health of our citizens?

(Although this message addresses the waiving of EMTALA rules for emergency
patients who are admitted, an even more consequential change is in the relaxation of the rules for specialist on-call backup of emergency services.

More preventable deaths are inevitable. Although adequate specialist coverage will always remain a problem, the immediate solution is not to merely diminish the obligation of specialists to provide coverage, but rather to ensure that they will be compensated when their services are required. Again, ensuring that everyone has adequate health care insurance is the first step toward solving these problems. Removing the issue of compensation allows for a less heated dialogue on the other important on-call disputes.)